Primary care: a comparison across five nations (part 4 of 6)

Chris van Weel is Emeritus Professorof Family Medicine at Radboud University, the Netherlands, and Professorof Primary Health Care Research at Australian National University, Canberra, Australia

Primary care in the Netherlands

What do populations need?

The aging population, the increasing number of people with chronic disease and (co)morbidity, the frail elderly, and the increasing number of migrants from Eastern Europe, the Middle East and Asia present a challenge for the health care system. The government increasingly promotes preventive and self-responsibility strategies for people to better manage their own health.

How does the system provide for these needs?

The Dutch health care system is led by primary care since the introduction of the "Sick Fund" law in 1941. From that time on, personal listing of people with a family physician is the guiding principle, and has remained in place after the 2006 revision of the health care system that introduced private insurance for all. Family physicians are the point of entry for people to contact the health care system. Specialists and hospital care can only be accessed after referral by the family physician. The ideology of “primary care lead” is reflected in the reality of daily practice: more than 95% of all episodes of care are covered in primary care, and family physicians remain actively involved in the management of the remaining part of the patient’s health care. Individual health care strategies are estimated to be responsible for a 25% decline in premature mortality, contributing slightly more than collective prevention strategies to premature mortality.

Who pays for the primary care system?

Personal health care is covered through “basic private health insurance” and includes essential curative care that has stood the test of efficacy. All insured residents contribute a flat rate premium and an income-dependent contribution. Health plans are by law required to cover family practice costs. Health insurers use a mixed model to pay family physicians: (i) in a capitation model for the patients on the physicians’ list and (ii) fee for service. Specialists and hospitals are paid for the actual services that have been provided through a diagnosis and treatment combination.

The guiding principle behind the 2006 health care system revision was to introduce a market principle with competition between providers. Insurers are able to negotiate special financial arrangements with individual practices for their insurees, based on established markers of quality. Health insurers are thus expected to act as the patient’s broker in finding the best care for the best price, thereby containing health care costs.

What are the strengths?

A strong point of the current Dutch health care system is that evidence-based health care policy has prevailed during the introduction of market-oriented reforms. Universal coverage and primary care lead have been preserved. This means that current health care can capitalize on the investment in family medicine and primary care over the last three decades. The interactions between academia and the field have made family practice the leading force in evidence-based medicine, resulting in a strong societal position.

What are the weaknesses?

In terms of the financial considerations, there are no indications yet that the system is better able to cope with the challenges of rising health care costs. In terms of the health care performance, there are grave concerns of the lack of coherence. Although the quality of the various medical disciplines is high (particularly family medicine), population health is ultimately determined by the ability of primary and secondary care to collaborate and interact. Rifts between primary care and secondary care can lead to poor health outcomes as the maternity care report has illustrated. It also may erode the cohesion between public health, individual health care and welfare, which in turn may result in the loss of effectiveness of primary care and impact the health of the population.